Examkin

Soru

Zorluk: KolayEstablishing Priorities

The charge nurse on a postoperative unit is determining which client requires immediate evaluation. Which client must be assessed first?

  1. A client who is 2 hours post-thyroidectomy and produces a high-pitched, harsh sound upon inhalationCevap
  2. B
    A client who is 1 day post-appendectomy and has a temperature of 99.4°F (37.4°C)
  3. C
    A client who underwent a total knee arthroplasty 24 hours ago and is requesting a prescribed analgesic
  4. D
    A client who is scheduled for an inguinal hernia repair tomorrow and is crying uncontrollably due to fear

Cevap

The client who is 2 hours post-thyroidectomy and produces a high-pitched, harsh sound upon inhalation.
The client who is post-thyroidectomy and exhibiting a high-pitched, harsh sound on inhalation (stridor) requires immediate assessment. Stridor indicates a narrowing or obstruction of the airway, often caused by edema, hemorrhage, or laryngeal nerve damage following neck surgery. Under the Airway, Breathing, Circulation (ABC) framework, maintaining a patent airway is always the highest clinical priority.

Adım Adım Çözüm

1
Analyze the clinical presentation of each assigned client.
The post-thyroidectomy client has stridor; the other clients present with expected postoperative pain, mild fever, or anxiety.
Identifying the severity and acuity of each client's condition is the first step in nursing triage.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The post-thyroidectomy client's symptom indicates an acute airway compromise, making them the highest priority.
Physiological survival needs, specifically maintaining a patent airway, must always be addressed before pain, expected inflammatory responses, or psychological distress.

Anahtar Kavram

Prioritization using the ABC (Airway, Breathing, Circulation) framework.
Bu soruyu puanla

Konular

Establishing Priorities

Bu konudan daha fazla soru